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Authorization Agreement to Replace Printed Bill with Electronically Mailed Bill

2. City of New Haven Utilities
   P.O. Box 570 <br> New Haven, IN 46774 <br> Phone: 260-748-7050

   P.O. Box 570
   New Haven, IN 46774
   Phone: 260-748-7050

4. I (we) hereby authorize City of New Haven to initiate sending electronically generated monthly bills (e-bill) for utility services and fees instead of a printed bill that has been previously delivered by the United States Postal Service (<abbr>USPS</abbr>). I also understand that this service is for property owners <b>only</b>. <br> <br> I understand that the e-statement will be the only monthly notification of amounts due and will be delivered as an Adobe <abbr>PDF</abbr> document attached to an electronic mail sent to the email address identified on this form. Failure to receive or loss of bill will not be accepted as an excuse for non-payment or waiver of penalties. <br> <br> This authority is to remain in full force and effect until the City of New Haven has received written notification from me (or either of us) of its termination thirty days prior to the next billing date.

   I (we) hereby authorize City of New Haven to initiate sending electronically generated monthly bills (e-bill) for utility services and fees instead of a printed bill that has been previously delivered by the United States Postal Service (USPS). I also understand that this service is for property owners only.
   
   I understand that the e-statement will be the only monthly notification of amounts due and will be delivered as an Adobe PDF document attached to an electronic mail sent to the email address identified on this form. Failure to receive or loss of bill will not be accepted as an excuse for non-payment or waiver of penalties.
   
   This authority is to remain in full force and effect until the City of New Haven has received written notification from me (or either of us) of its termination thirty days prior to the next billing date.

6. Who Is Filling out the Form

   1. Owner
   2. Renter

8. Name

10. Email Address

12. Service Address

14. Phone Number

16. Electronic Signature

17. Date
    Date

Leave This Blank:


19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

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